Healthcare Provider Details

I. General information

NPI: 1083672034
Provider Name (Legal Business Name): ROBERT FLYNN LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 COMMERCE DR STE C
GRAYSLAKE IL
60030-1646
US

IV. Provider business mailing address

10 SEXTANT DR
THIRD LAKE IL
60030-2617
US

V. Phone/Fax

Practice location:
  • Phone: 847-293-1698
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180-002585
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180002585
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: